Improving Quality Care and Patient Safety With Implementation of an Oversew Stitch in Lumbar Drains.

ABSTRACT: The lumbar drain exit site purse string oversew stitch is a well-described bedside intervention to stop or prevent cerebrospinal fluid (CSF) leak. It is not routinely placed at the time of lumbar drain placement. Via four plan-do-study-act (PDSA) cycles, we test the effect of prophylactic utilization of the lumbar drain exit site oversew stitch on house officers' paging burden, need to redress the drain, need to oversew the drain to stop a CSF leak, and need to replace the drain. We found that the simple act of placing an oversew stitch at the time of lumbar drain placement significantly reduced paging burden and reduced the frequency at which an oversew stitch was required to stop a CSF leak. Subjectively, during PDSA cycles during which overstitches were placed prophylactically, in-house residents perceived that there were less lumbar drains on service, although objectively, the overall number was unchanged. We conclude that prophylactic lumbar drain exit site stitch placement reduces risk and bedside interventions for patients and also reduces overall call burden on house officers. This simple intervention may therefore provide a more widespread improvement in care quality beyond lumbar drain care because house officers experience less burnout during their call shifts.

Flexible, scalable, high channel count stereo-electrode for recording in the human brain.

Over the past decade, stereotactically placed electrodes have become the gold standard for deep brain recording and stimulation for a wide variety of neurological and psychiatric diseases. Current electrodes, however, are limited in their spatial resolution and ability to record from small populations of neurons, let alone individual neurons. Here, we report on an innovative, customizable, monolithically integrated human-grade flexible depth electrode capable of recording from up to 128 channels and able to record at a depth of 10 cm in brain tissue. This thin, stylet-guided depth electrode is capable of recording local field potentials and single unit neuronal activity (action potentials), validated across species. This device represents an advance in manufacturing and design approaches which extends the capabilities of a mainstay technology in clinical neurology.

Modular Phoneme Processing in Human Superior Temporal Gyrus.

Modular organization is fundamental to cortical processing, but its presence is human association cortex is unknown. We characterized phoneme processing with 128-1024 channel micro-arrays at 50-200µm pitch on superior temporal gyrus of 7 patients. High gamma responses were highly correlated within ~1.7mm diameter modules, sharply delineated from adjacent modules with distinct time-courses and phoneme-selectivity. We suggest that receptive language cortex may be organized in discrete processing modules.

Intraoperative application and early experience with novel high-resolution, high-channel-count thin-film electrodes for human microelectrocorticography.

OBJECTIVE: The study objective was to evaluate intraoperative experience with newly developed high-spatial-resolution microelectrode grids composed of poly(3,4-ethylenedioxythiophene) with polystyrene sulfonate (PEDOT:PSS), and those composed of platinum nanorods (PtNRs). METHODS: A cohort of patients who underwent craniotomy for pathological tissue resection and who had high-spatial-resolution microelectrode grids placed intraoperatively were evaluated. Patient demographic and baseline clinical variables as well as relevant microelectrode grid characteristic data were collected. The primary and secondary outcome measures of interest were successful microelectrode grid utilization with usable resting-state or task-related data, and grid-related adverse intraoperative events and/or grid dysfunction. RESULTS: Included in the analysis were 89 cases of patients who underwent a craniotomy for resection of neoplasms (n = 58) or epileptogenic tissue (n = 31). These cases accounted for 94 grids: 58 PEDOT:PSS and 36 PtNR grids. Of these 94 grids, 86 were functional and used successfully to obtain cortical recordings from 82 patients. The mean cortical grid recording duration was 15.3 ± 1.15 minutes. Most recordings in patients were obtained during experimental tasks (n = 52, 58.4%), involving language and sensorimotor testing paradigms, or were obtained passively during resting state (n = 32, 36.0%). There were no intraoperative adverse events related to grid placement. However, there were instances of PtNR grid dysfunction (n = 8) related to damage incurred by suboptimal preoperative sterilization (n = 7) and improper handling (n = 1); intraoperative recordings were not performed. Vaporized peroxide sterilization was the most optimal sterilization method for PtNR grids, providing a significantly greater number of usable channels poststerilization than did steam-based sterilization techniques (median 905.0 [IQR 650.8-935.5] vs 356.0 [IQR 18.0-597.8], p = 0.0031). CONCLUSIONS: High-spatial-resolution microelectrode grids can be readily incorporated into appropriately selected craniotomy cases for clinical and research purposes. Grids are reliable when preoperative handling and sterilization considerations are accounted for. Future investigations should compare the diagnostic utility of these high-resolution grids to commercially available counterparts and assess whether diagnostic discrepancies relate to clinical outcomes.

Rapid Passive Gamma Mapping as an Adjunct to Electrical Stimulation Mapping for Functional Localization in Resection of Primary Brain Neoplasms.

OBJECTIVE: We examined the utility of passive high gamma mapping (HGM) as an adjunct to conventional awake brain mapping during glioma resection. We compared functional and survival outcomes before and after implementing intraoperative HGM. METHODS: This was a retrospective cohort study of 75 patients who underwent a first-time, awake craniotomy for glioma resection. Patients were stratified by whether their operation occurred before or after the implementation of a U.S. Food and Drug Administration-approved high-gamma mapping tool in July 2017. RESULTS: The preimplementation and postimplementation cohorts included 28 and 47 patients, respectively. Median intraoperative time (261 vs. 261 minutes, P = 0.250) and extent of resection (97.14% vs. 98.19%, P = 0.481) were comparable between cohorts. Median Karnofsky performance status at initial follow-up was similar between cohorts (P = 0.650). Multivariable Cox regression models demonstrated an adjusted hazard ratio for overall survival of 0.10 (95% confidence interval: 0.02-0.43, P = 0.002) for the postimplementation cohort relative to the preimplementation cohort. Progression-free survival adjusted for insular involvement showed an adjusted hazard ratio of 1.00 (95% confidence interval: 0.49-2.06, P = 0.999) following HGM implementation. Falling short of statistical significance, prevalence of intraoperative seizures and/or afterdischarges decreased after HGM implementation as well (12.7% vs. 25%, P = 0.150). CONCLUSIONS: Our results tentatively indicate that passive HGM is a safe and potentially useful adjunct to electrical stimulation mapping for awake cortical mapping, conferring at least comparable functional and survival outcomes with a nonsignificant lower rate of intraoperative epileptiform events. Considering the limitations of our study design and patient cohort, further investigation is needed to better identify optimal use cases for HGM.

Responsive deep brain stimulation guided by ventral striatal electrophysiology of obsession durably ameliorates compulsion.

Treatment-resistant obsessive-compulsive disorder (OCD) occurs in approximately one-third of OCD patients. Obsessions may fluctuate over time but often occur or worsen in the presence of internal (emotional state and thoughts) and external (visual and tactile) triggering stimuli. Obsessive thoughts and related compulsive urges fluctuate (are episodic) and so may respond well to a time-locked brain stimulation strategy sensitive and responsive to these symptom fluctuations. Early evidence suggests that neural activity can be captured from ventral striatal regions implicated in OCD to guide such a closed-loop approach. Here, we report on a first-in-human application of responsive deep brain stimulation (rDBS) of the ventral striatum for a treatment-refractory OCD individual who also had comorbid epilepsy. Self-reported obsessive symptoms and provoked OCD-related distress correlated with ventral striatal electrophysiology. rDBS detected the time-domain area-based feature from invasive electroencephalography low-frequency oscillatory power fluctuations that triggered bursts of stimulation to ameliorate OCD symptoms in a closed-loop fashion. rDBS provided rapid, robust, and durable improvement in obsessions and compulsions. These results provide proof of concept for a personalized, physiologically guided DBS strategy for OCD.

Responsive neurostimulation as a treatment for super-refractory focal status epilepticus: a systematic review and case series.

OBJECTIVE: Super-refractory status epilepticus (SRSE) has high rates of morbidity and mortality. Few published studies have investigated neurostimulation treatment options in the setting of SRSE. This systematic literature review and series of 10 cases investigated the safety and efficacy of implanting and activating the responsive neurostimulation (RNS) system acutely during SRSE and discusses the rationale for lead placement and selection of stimulation parameters. METHODS: Through a literature search (of databases and American Epilepsy Society abstracts that were last searched on March 1, 2023) and direct contact with the manufacturer of the RNS system, 10 total cases were identified that utilized RNS acutely during SE (9 SRSE cases and 1 case of refractory SE [RSE]). Nine centers obtained IRB approval for retrospective chart review and completed data collection forms. A tenth case had published data from a case report that were referenced in this study. Data from the collection forms and the published case report were compiled in Excel. RESULTS: All 10 cases presented with focal SE: 9 with SRSE and 1 with RSE. Etiology varied from known lesion (focal cortical dysplasia in 7 cases and recurrent meningioma in 1) to unknown (2 cases, with 1 presenting with new-onset refractory focal SE [NORSE]). Seven of 10 cases exited SRSE after RNS placement and activation, with a time frame ranging from 1 to 27 days. Two patients died of complications due to ongoing SRSE. Another patient's SE never resolved but was subclinical. One of 10 cases had a device-related significant adverse event (trace hemorrhage), which did not require intervention. There was 1 reported recurrence of SE after discharge among the cases in which SRSE resolved up to the defined endpoint. CONCLUSIONS: This case series offers preliminary evidence that RNS is a safe and potentially effective treatment option for SRSE in patients with 1-2 well-defined seizure-onset zone(s) who meet the eligibility criteria for RNS. The unique features of RNS offer multiple benefits in the SRSE setting, including real-time electrocorticography to supplement scalp EEG for monitoring SRSE progress and response to treatment, as well as numerous stimulation options. Further research is indicated to investigate the optimal stimulation settings in this unique clinical scenario.

Analysis of spinal canal diameter in the placement of thoracic spinal cord stimulator paddle leads.

BACKGROUND: Neurologic deficit is known as a rare complication of thoracic spinal cord stimulator (SCS) paddle lead implantation, but many believe its incidence after SCS paddle lead placement is under-reported. It is possible that imaging characteristics may be used to help predict safe paddle lead placement. OBJECTIVE: This imaging study was undertaken to determine the minimum canal diameter required for safe paddle lead placement. METHODS: Patients who underwent thoracic laminotomy for new SCS paddle lead placement from January 2018 to March 2023 were identified retrospectively. Preoperative thoracic canal diameter was measured in the sagittal plane perpendicular to the disc space from T5/6 to T11/12. These thoracic levels were chosen because they span the most common levels targeted for SCS placement. Patients with and without new neurologic deficits were compared using a Mann-Whitney U-test. RESULTS: Of 185 patients initially identified, 180 had thoracic imaging available for review. One (0.5%) and 2 (1.1%) of 185 patients complained of permanent and transient neurologic deficit after thoracic SCS placement, respectively. Patients with neurologic deficits had average canal diameters of <11 mm. The average canal diameter of patients with and without neurologic deficits was 10.2 mm (range 6.1-12.9 mm) and 13.0 mm (range 5.9-20.2), respectively (p < 0.0001). CONCLUSION: Postoperative neurologic deficit is an uncommon complication after thoracic laminotomy for SCS paddle lead placement. The authors recommend ensuring a starting thoracic canal diameter of at least 12 mm to accommodate a SCS paddle lead measuring 2 mm thick to ensure a final diameter of >10 mm. If canal diameter is <12 mm, aggressive undercutting of the lamina, a second laminotomy, or placement of smaller SCS wire leads should be considered.

Effect of spinal cord stimulation on quality of life and opioid consumption in patients with failed back surgery syndrome.

BACKGROUND: Failed back surgery syndrome (FBSS) is a constellation of conditions occurring after spine surgeries, characterized by the presence of persistent or recurring low back pain that has a significant impact on patients' quality of life. Neuromodulation in the form of Spinal Cord Stimulation (SCS) is considered an indispensable treatment modality in the management of certain chronic pain conditions and it is showing good results for improvement in pain scores and functional capacity of the FBSS patients. OBJECTIVES: To assess the change in pain scores, quality of life, and opioid medication intake as an outcome of neuromodulation procedures performed on patients diagnosed with failed back surgery syndrome, and to detect the post-procedure complications. METHODS: A prospective observational study was conducted at two university hospitals in Egypt and the U.S.A. during the period from September 2019 to August 2021 for patients who underwent spinal cord stimulation procedures for FBSS with follow-up period of at least 1 year. Patients who are 18 years old or older diagnosed with FBSS for more than 6 months and treated with spinal cord stimulation with successful trials during this time frame were included in the study. RESULTS: Thirty-four patients were included in this study who had successful SCS trials and underwent permanent implantation of SCS devices with post-procedure follow-up period of 12 months. Patients showed a median pain numerical rating scale (NRS) of 7/10 at baseline with a median NRS of 4/10 through the follow-up period. Basic mobility and daily activity scores assessed by activity measure of post-acute care (AM-PAC) showed significant improvement from the mean of 16.87 ± 2.74 at baseline to a mean of 19.97 ± 2.93 through follow-up. In addition, there was a reduction in opioid medication usage. Post-procedure complications was of low percentage with the most detected were battery dysfunction in 7 patients and pocket pain in 6 patients. Reoperation was needed in 13 patients with 4 needed just revision and 9 patients required a complete removal of the device. CONCLUSION: Spinal cord stimulation is an effective modality of treatment for cases of failed back surgery syndrome with a statistically significant reduction in pain scores and a significant improvement in quality of life. Also, it achieves a recognizable reduction in opioid analgesic medications, with a reliable safety profile as detected with the recorded post-procedure complications. However, randomized controlled trials with more patients and long-term follow-up are highly recommended.

Deciphering spatially distinct immune microenvironments in glioblastoma using ferumoxytol and gadolinium-enhanced and FLAIR hyperintense MRI phenotypes.

Background: MRI with gadolinium (Gd)-contrast agents is used to assess glioblastoma treatment response but does not specifically reveal heterogeneous biology or immune microenvironmental composition. Ferumoxytol (Fe) contrast is an iron nanoparticle that localizes glioblastoma macrophages and microglia. Therefore, we hypothesized that the use of Fe contrast improves upon standard Gd-based T1-weighted and T2/FLAIR analysis by specifically delineating immune processes. Methods: In this, HIPAA-compliant institutional review board-approved prospective study, stereotactic biopsy samples were acquired from patients with treatment-naïve and recurrent glioblastoma based on MR imaging phenotypes; Gd and Fe T1 enhancement (Gd+, Fe+) or not (Gd-, Fe-), as well as T2-Flair hyperintensity (FLAIR+, FLAIR-). Analysis of genetic expression was performed with RNA microarrays. Imaging and genomic expression patterns were compared using false discovery rate statistics. Results: MR imaging phenotypes defined a variety of immune pathways and Hallmark gene sets. Gene set enrichment analysis demonstrated that Gd+, Fe+, and FLAIR+ features were individually correlated with the same 7 immune process gene sets. Fe+ tissue showed the greatest degree of immune Hallmark gene sets compared to Gd+ or Flair+ tissues and had statistically elevated M2 polarized macrophages, among others. Importantly, the FLAIR+ Gd+ and Fe- imaging phenotypes did not demonstrate expression of immune Hallmark gene sets. Conclusions: Our study demonstrates the potential of Fe and Gd-enhanced MRI phenotypes to reveal spatially distinct immune processes within glioblastoma. Fe improves upon the standard of care Gd enhancement by specifically localizing glioblastoma-associated inflammatory processes, providing valuable insights into tumor biology.

Informed Consent for Spine Procedures: Best Practice Guideline from the American Society of Pain and Neuroscience (ASPN).

Introduction: The evolution of treatment options for painful spinal disorders in diverse settings has produced a variety of approaches to patient care among clinicians from multiple professional backgrounds. The American Society of Pain and Neuroscience (ASPN) Best Practice group identified a need for a multidisciplinary guideline regarding appropriate and effective informed consent processes for spine procedures. Objective: The ASPN Informed Consent Guideline was developed to provide clinicians with a comprehensive evaluation of patient consent practices during the treatment of spine pathology. Methods: After a needs assessment, ASPN determined that best practice regarding proper informed consent for spinal procedures was needed and a process of selecting faculty was developed based on expertise, diversity, and knowledge of the subject matter. A comprehensive literature search was conducted and when appropriate, evidence grading was performed. Recommendations were based on evidence when available, and when limited, based on consensus opinion. Results: Following a comprehensive review and analysis of the available evidence, the ASPN Informed Consent Guideline group rated the literature to assist with specification of best practice regarding patient consent during the management of spine disorders. Conclusion: Careful attention to informed consent is critical in achieving an optimal outcome and properly educating patients. This process involves a discussion of risks, advantages, and alternatives to treatment. As the field of interventional pain and spine continues to grow, it is imperative that clinicians effectively educate patients and obtain comprehensive informed consent for invasive procedures. This consent should be tailored to the patient's specific needs to ensure an essential recognition of patient autonomy and reasonable expectations of treatment.

The American Society of Pain and Neuroscience (ASPN) Guidelines for Radiofrequency Ablative Procedures in Patients with Implanted Devices.

Radiofrequency ablation (RFA) is a treatment modality used in interventional pain management to treat several conditions including chronic neck or back pain, sacroiliac joint pain, major joint pain, and pain from sites that can be isolated to a sensory nerve amenable to RFA. The goals of such procedures are to reduce pain, improve function, delay need for surgical intervention, and reduce pain medication consumption. As applications for RFA expand through novel techniques and nerve targets, there is concern with how RFA may impact patients with implanted medical devices. Specifically, the electrical currents used in RFA produce electromagnetic interference, which can result in unintentional energy transfer to implanted devices. This may also interfere with device function or cause damage to the device itself. As the number of patients with implanted devices increases, it is imperative to establish guidelines for the management of implanted devices during RFA procedures. This review aims to establish guidelines to assist physicians in the preoperative, intraoperative, and postoperative management of implanted devices in patients undergoing procedures using radiofrequency energy. Here, we provide physicians with background knowledge and a summary of current evidence to allow safe utilization of RFA treatment in patients with implanted devices such as cardiac implantable electronic devices, spinal cord stimulators, intrathecal pumps, and deep brain stimulators. While these guidelines are intended to be comprehensive, each patient should be assessed on an individual basis to optimize outcomes.

Combined cervical and thoracic spinal cord stimulation for chronic pain: A systematic literature review.

OBJECTIVES: Spinal cord stimulation (SCS) is conventionally placed at either cervical or thoracic spinal regions to treat chronic pain. However, for patients with multiarea pain, concomitant cervical and thoracic SCS (ctSCS) may be necessary to provide sufficient coverage. It remains unknown whether ctSCS is effective and safe. Thus, we aimed to survey the existing literature and assess the efficacy and safety of ctSCS. METHODS: A systematic review of the literature was performed according to the 2020 PRISMA guidelines to investigate pain, functional, and safety outcomes related to ctSCS. Articles between 1990 and 2022 available through PubMed, Web of Science, Scopus, and Cochrane Library databases were included if they assessed these outcomes in the context of ctSCS. Data extracted from articles included study type, number of ctSCS implantations, stimulation parameters, indications for implantation, complications, and frequency. The Newcastle-Ottawa scale was used to assess risk of bias. RESULTS: Three primary studies met our inclusion criteria. Overall, ctSCS was effective in providing analgesia. Pain severity was captured with patient-reported pain scales and changes in analgesic requirements. Various metrics were used to quantify quality of life and functional outcomes. Failed back surgery syndrome was the most common indication for ctSCS implantation. Implanted pulse generator pocket pain was the most common postoperative adverse event. CONCLUSIONS: Despite the limited evidence available, ctSCS seems to be effective and generally well tolerated. The dearth of relevant primary literature illustrates a knowledge gap, and future studies are needed to better clarify the efficacy and safety profile of this SCS variant.

Supraorbital Nerve Stimulation for Facial Pain.

PURPOSE OF REVIEW: Chronic facial pain is considered one of the conditions that affect quality of daily life of patients significantly and makes them seek medical help. Intractable facial pain with failed trials of medical treatment and other pain management therapies presents a challenge for neurologists, pain specialists, and neurosurgeons. We describe the possibility of proposing peripheral nerve stimulation of the supraorbital nerves to treat patients with medically intractable facial pain. Stimulation of the supraorbital nerves is performed using percutaneously inserted electrodes that are positioned in the epi-fascial plane, traversing the course of the supraorbital nerves. The procedure has two phases starting with a trial by temporary electrodes that are inserted under fluoroscopic guidance and are anchored to the skin. This trial usually lasts for a few days to 2 weeks. If successful, we proceed to the insertion of a permanent electrode that is tunneled under the skin behind the ear toward the infraclavicular region in which we make a pocket for the implantable pulse generator. RECENT FINDINGS: This procedure has been used in multiple patients with promising results which was published in literature. Literature shows that it provides relief of medically intractable pain, without the need for destructive procedures or more central modulation approaches with a preferable safety profile compared to other invasive procedures. Supraorbital nerve stimulation is now considered a valid modality of treatment for patients with medically intractable facial pain and can be offered as a reliable alternative for the patients while discussing the proper plan of management.

Mismatch repair-deficient glioma with spatially distinct IDH-mutant and IDH-wild type components arising in the setting of Lynch syndrome.

Pathogenic mutations in MLH1, MSH2, PMS2, and MSH6 compromise DNA mismatch repair mechanisms and in the heterozygous state result in Lynch syndrome, which is typified by a predisposition to endometrial, ovarian, colorectal, gastric, breast, hematologic, and soft tissue cancers. Rarely, germline pathogenic aberrations in these genes are associated with the development of primary central nervous system tumors. We present a report of an adult female with no prior cancer history who presented with a multicentric, infiltrative supratentorial glioma involving both the left anterior temporal horn and left precentral gyrus. Surgical treatment and neuropathological/molecular evaluation of these lesions revealed discordant isocitrate dehydrogenase (IDH) status and histologic grade at these spatially distinct disease sites. A frameshift alteration within the MLH1 gene (p.R217fs*12, c.648delT) was identified in both lesions and subsequently identified in germline testing of a blood sample, consistent with Lynch syndrome. Despite distinct histopathologic features and divergent IDH status of the patient's tumors, the molecular findings suggest that both sites of intracranial neoplasia may have developed as a consequence of underlying monoallelic germline mismatch repair deficiency. This case illustrates the importance of characterizing the genetic profile of multicentric gliomas and highlights the oncogenic potential of germline mismatch repair gene pathogenic alterations within central nervous system gliomas.

Stereotactic electroencephalography in epilepsy patients for mapping of neural circuits related to emotional and psychiatric behaviors: a systematic review.

OBJECTIVE: Stereotactic electroencephalography (sEEG) is an increasingly utilized method for identifying electrophysiological processes underlying sensorimotor, cognitive, and emotional behaviors. In this review, the authors outline current research using sEEG to investigate the neural activity underlying emotional and psychiatric behaviors. Understanding the current structure of intracranial research using sEEG will inform future studies of psychiatric disease and therapeutics for effective neuromodulation. METHODS: The authors conducted a comprehensive systematic review of studies according to PRISMA guidelines to investigate behaviors related to psychiatric conditions in patients with epilepsy undergoing monitoring with sEEG. Articles indexed on PubMed between 2010 and 2022 were included if they studied emotions or affective behaviors or met the National Institute of Mental Health Research Domain Criteria positive and negative valence domains. Data extracted from articles included study sample size, paradigms and behavioral tasks employed, cortical and subcortical targets, EEG analysis methods, and identified electrophysiological activity underlying the studied behavior. The Newcastle-Ottawa Scale was used to assess bias risk. RESULTS: Thirty-two primary articles met inclusion criteria. Study populations ranged from 3 to 39 patients. The most common structures investigated were the amygdala, insula, orbitofrontal cortex (OFC), hippocampus, and anterior cingulate cortex (ACC). Paradigms, stimuli, and behavioral tasks widely varied. Time-frequency analyses were the most common, followed by connectivity analyses. Multiple oscillations encoded a variety of behaviors related to emotional and psychiatric conditions. High gamma activity was observed in the amygdala and anterior insula in response to aversive audiovisual stimuli and in the OFC in response to reward processing. ACC beta band power increases and hippocampal-amygdala beta coherence variations were predictive of worsening mood states. Insular and amygdalar theta oscillations encoded social pain and fear learning, respectively. Most studies performed passing recordings, allowing for the decoding of affective states and depression symptoms, while other studies utilized direct stimulation, such as in the OFC to improve mood symptoms. CONCLUSIONS: Stereotactic EEG in epilepsy has identified multiple corticolimbic structures with specific oscillatory and synchronization activity underlying a diverse range of behaviors related to emotions and affective conditions. Given the heterogeneity of psychiatric conditions, sEEG provides an opportunity to study these neural correlates to develop personalized effective neuromodulatory treatments. Future studies should focus on optimizing paradigms and tasks to investigate a broad range of behavioral phenotypes that overlap across psychiatric conditions.

Response to Preoperative Dexamethasone Predicts Postoperative Neurological Improvement of Focal Neurological Deficits in Patients With Brain Metastases.

BACKGROUND: Steroids are used ubiquitously in the preoperative management of patients with brain tumor. The rate of improvement in focal deficits with steroids and the prognostic value of such a response are not known. OBJECTIVE: To determine the rate at which focal neurological deficits respond to preoperative corticosteroids in patients with brain metastases and whether such an improvement could predict long-term recovery of neurological function after surgery. METHODS: Patients with brain metastases and related deficits in language, visual field, or motor domains who received corticosteroids before surgery were identified. Characteristics between steroid responders and nonresponders were compared. RESULTS: Ninety six patients demonstrated a visual field (13 patients), language (19), or motor (64) deficit and received dexamethasone in the week before surgery (average cumulative dose 43 mg; average duration 2.7 days). 38.5% of patients' deficits improved with steroids before surgery, while 82.3% of patients improved by follow-up. Motor deficits were more likely to improve both preoperatively ( P = .014) and postoperatively ( P = .010). All 37 responders remained improved at follow-up whereas 42 of 59 (71%) of nonresponders ultimately improved ( P < .001). All other clinical characteristics, including dose and duration, were similar between groups. CONCLUSION: A response to steroids before surgery is highly predictive of long-term improvement postoperatively in brain metastasis patients with focal neurological deficits. Lack of a response portends a somewhat less favorable prognosis. Duration and intensity of therapy do not seem to affect the likelihood of response.

Survival, Functional, and Seizure Control Outcomes After Resection of Perirolandic World Health Organization Grade II and III Gliomas: A Single-Center Retrospective Review.

OBJECTIVE: We aimed to assess, in patients with perirolandic gliomas and gliomas originating from other regions, survival, functional outcomes, and seizure control and, in addition, to identify any clinical characteristics predictive of progression-free survival, overall survival, and seizure control. METHODS: We retrospectively analyzed 87 patients who underwent resection of World Health Organization grade II or III gliomas at a single institution between 2009 and 2021. Tumors were classified by topographic involvement. One-year postoperative functional status was quantified with Karnofsky Performance Status. One-year seizure control was defined by Engel seizure classification. Dichotomous and categorical variables were reported as counts and percentages and compared using Fisher exact test. A Cox regression model was used to identify covariates that affect progression-free survival and overall survival. RESULTS: Patients with perirolandic gliomas had similar survival and functional outcomes to patients with gliomas from other regions and a low rate of lasting neurologic deficits. Patients with perirolandic gliomas had comparatively worse long-term seizure outcomes (approached statistical significance). Perirolandic involvement (hazard ratio [HR], 0.10; 95% confidence interval [CI], 0.02-0.46; P = 0.005) and preoperative seizures (HR, 0.14; 95% CI, 0.02-0.62; P = 0.017) conferred a lower likelihood of durable seizure control, whereas increased extent of resection (HR, 1.07; 95% CI, 1.03-1.12; P = 0.003) enhanced the likelihood of seizure freedom. CONCLUSIONS: Despite proximity to or presence in eloquent structures, perirolandic gliomas can largely be resected without incurring worse functional outcomes. Patients with perirolandic gliomas should be considered for maximal safe resection to optimize survival outcomes and improve seizure control.